Compositions and Methods for Treating Renal Failure

ABSTRACT

The present disclosure relates to the use of angiotensin II in therapeutic methods for the treatment of renal failure, especially renal failure associated with cirrhosis.

RELATED APPLICATIONS

This application is a continuation of Patent Cooperation TreatyApplication Serial Number PCT/US2014/035511, filed Apr. 25, 2014, whichclaims the benefit of priority to U.S. Provisional Patent ApplicationSer. No. 61/816,578, filed Apr. 26, 2013, the contents of which arehereby incorporated by reference herein in their entirety.

BACKGROUND OF THE INVENTION

Hepatorenal Syndrome (HRS) is progressive renal failure associated withliver cirrhosis or fulminant liver failure. It is a life-threateningcondition in which kidney function rapidly declines resulting in >50%mortality in ≦6 months. HRS occurs in 18% of cirrhotic patients withinone year of diagnosis and in 39% of patients within five years. Based onthe speed of progression of renal failure, as measured by serumcreatinine level, HRS is categorized into two types. Type 1 HRS is themore rapidly progressing type and is characterized by a 100% increase inserum creatinine to >2.5 mg/dL within two weeks. Less than 10% survivehospitalization, and the median survival is only two weeks. Type 2 HRSis slower progressing, with serum creatinine rising gradually. However,type 2 HRS patients can develop sudden renal failure and becomediagnosed with type 1 HRS. Although HRS can occur spontaneously, othercommon precipitating factors are bacterial infections, gastrointestinalhemorrhage, therapeutic paracentesis, etc.

Deteriorating liver function is believed to be the underlying cause ofchanges in the circulation to the viscera, altering blood flow and bloodvessel tone in the kidneys. The renal failure in HRS is a consequence ofthese changes in blood flow. The presence of elevated pressure in theportal vein (portal hypertension) in patients with liver damage isthought to result in secretion of vasodilator substances in thesplanchnic circulation that causes systemic arterial underfilling. Thishypotensive state triggers vasoconstriction in the kidney as a means torestore systemic blood pressure. However, the effect of this restorationis insufficient to counteract the mediators of vasodilation incirculation, leading to persistent “underfilling” of the renalcirculation and worsening renal vasoconstriction, leading to renalfailure.

HRS is thought to be part of a spectrum of illness associated withincreased pressure in the portal vein circulation, which begins with thedevelopment of fluid in the abdomen (ascites). Ascites is a majorcomplication associated with HRS and is exacerbated by impaired sodiumexcretion. The spectrum continues with diuretic-resistant ascites, wherethe kidneys are unable to excrete sufficient sodium to clear the fluideven with the use of diuretic medications. Most individuals with type 2HRS have diuretic-resistant ascites before they develop deterioration inkidney function.

Liver transplantation is the only available cure for HRS; however, mostpatients do not live long enough to have the procedure. Currentlyavailable treatment for HRS is largely supportive and administered in aneffort to bridge the patient to transplantation. Volume support withsalt-poor albumin is the mainstay of treatment, as HRS patients havechronic total body sodium overload despite low serum sodium levels andhypotension. Use of vasoconstrictors, such as terlipressin orvasopressin, is thought to be effective by restoring pressure in thevasodilated splanchnic circulation. However, the adverse effects ofreduced organ perfusion and marginal effect on sodium excretion limittheir utility (Gines, P., et al., Hepatorenal syndrome. Lancet, 2003.362(9398): p. 1819-27; Lata, J., Hepatorenal syndrome. World JGastroenterol, 2012. 18(36): p. 4978-84; Salerno, F., et al., Diagnosis,prevention and treatment of hepatorenal syndrome in cirrhosis. Gut,2007. 56(9): p. 1310-8). Therefore, there is an urgent need for newagents to improve renal function at least sufficient to help supportpatients prior to transplantation.

SUMMARY OF THE INVENTION

In part, this disclosure proposes the method of administering acomposition comprising angiotensin II for the treatment of renal failureassociated with cirrhosis. In some embodiments, prior to theadministration of the composition comprising angiotensin II, a patientmay have a serum creatinine level greater than 1.5 mg/dl. In addition to(or in some cases instead of) serum creatinine level greater than 1.5mg/dl, the patient may also have a 24-hour serum creatinine clearance ofless than 40 ml/min. In some embodiments, the method of treating renalfailure associated with cirrhosis in a patient may comprise measuringserum creatinine level and/or 24-hour serum creatinine clearance of apatient; and if a) the measured serum creatinine level is greater than1.5 mg/dl and/or b) the measured 24-hour serum creatinine clearance isless than 40 ml/min, then administering to the patient a compositioncomprising angiotensin II. In certain such embodiments, if the measuredserum creatinine level is not greater than 1.5 mg/dl and/or the measured24-hour serum creatinine clearance is not less than 40 ml/min, then thepatient does not receive a composition comprising angiotensin II. Therenal failure may be hepatorenal syndrome. The patient may be a human.

In some embodiments, a composition comprising angiotensin II may beadministered at a rate equal to or greater than 0.032 ng/kg/min, 0.32ng/kg/min, 1.6 ng/kg/min, or 1 ng/kg/min; or at a rate in the range of0.5 ng/min to 100 ug/min, 0.4 to 45 ug/min or 0.12 to 19 ug/min. Theconcentration of angiotensin II in the composition may be at least 16ug/ml. The composition comprising angiotensin II may be administered ata rate sufficient to achieve an increase in blood pressure of at leastabout 10-15 mmHg and optionally continued to administer for at leastabout 30 minutes thereafter. In some embodiments, the compositioncomprising angiotensin II may be administered at a variable rate basedon mean arterial pressure in a patient, wherein the mean arterialpressure does not exceed 80 mmHg, 90 mmHg, 100 mmHg, 110 mmHg or 120mmHg. For example, the rate of administration of the angiotensin II canbe modulated manually and/or automatically in response to measurementsof the patient's mean arterial pressure obtained periodically orsporadically during treatment, e.g., to maintain a mean arterialpressure at this level, or within a predetermined range (e.g., 80-110mmHg). The composition comprising angiotensin II may be administeredover a period of time of at least 8 hours; at least 24 hours; or from 8hours to 24 hours. The composition comprising angiotensin II may beadministered continuously for at least 2-6 days, such as 2-11 days,continuously for 2-6 days, or for 8 hours a day over a period of atleast 2-6 days, such as 2-11 days.

In another aspect, the invention provides a method of assessing theresponse of a patient (such as a human) with renal failure associatedwith cirrhosis (such as hepatorenal syndrome) to angiotensin therapy,comprising administering to the patient an initial dose of a compositioncomprising angiotensin II (which may be a therapeutic dose or asub-therapeutic dose, for example, adose less than 1 ng/kg/min or about1 ng/kg/min) and testing the patient for a change in a therapeuticparameter (e.g., serum creatinine level, estimated glomerular filtrationrate, serum sodium level, serum potassium level, urine sodiumconcentration, or blood pressure). For example, the therapeuticparameter of the patient can be assessed prior to administering theinitial dose and again after administering the initial dose (e.g., atleast half an hour later, preferably at least one hour later and/or upto 8 hours later, preferably up to 6 hours later, such as between 1 and6 hours after administering the initial dose). Comparing the assessmentof the therapeutic parameter after administering the initial dose to theassessment made prior to administering the initial dose will indicatewhether the parameter is increasing or decreasing as a result of theangiotensin therapy. Typically, a decrease in the patient's serumcreatinine level, urine sodium concentration, or serum potassium levelor an increase in the patient's blood pressure, serum sodium level, orestimated glomerular filtration rate is indicative of a positiveresponse to the angiotensin therapy. In certain embodiments, where thepatient exhibits a positive response to the therapy, the method furthercomprises administering an additional dose of angiotensin II to thepatient. If a patient exhibits a negative response (e.g., an increase inthe patient's serum creatinine level, urine sodium concentration, orserum potassium level or a decrease in the patient's blood pressure,serum sodium level, or estimated glomerular filtration rate), thepatient will typically receive no additional doses of angiotensintherapy. If a patient exhibits no response or an insignificant response,the method may further comprise administering a higher dose of thecomposition than the initial dose and further testing the patient for aresponse to the higher dose. Alternatively, if the patient exhibits noresponse or an insignificant response, the patient may receive nofurther doses of angiotensin therapy.

In certain embodiments of the method of assessing the response, themethod may further comprise, prior to administering the composition tothe patient, measuring serum creatinine level and/or 24-hour serumcreatinine clearance of the patient; and if a) the measured serumcreatinine level is greater than 1.5 mg/dl and/or b) the measured24-hour serum creatinine clearance is less than 40 ml/min, administeringto the patient the composition. In certain such embodiments, if themeasured serum creatinine level is not greater than 1.5 mg/dl and/or themeasured 24-hour serum creatinine clearance is not less than 40 ml/min,then the patient does not receive a composition comprising angiotensinII.

In some embodiments, the composition comprising angiotensin II may beselected from 5-valine angiotensin II acetate, 5-valine angiotensin IIamide, 5-L-isoleucine angiotensin II acetate, and 5-L-isoleucineangiotensin II amide, or a pharmaceutically acceptable salt thereof,preferably manufactured under current good manufacturing conditions(cGMP). The composition comprising angiotensin II may be suitable forparenteral administration, e.g., for injection or intravenous infusion.In some embodiments, the composition comprising angiotensin II mayfurther include an additional pharmaceutical agent, e.g., apharmaceutical agent useful for the treatment of the renal failureassociated with cirrhosis, such as terlipressin, norepinephrine, ormidodrine.

DETAILED DESCRIPTION OF THE INVENTION

Angiotensin II is a peptide hormone naturally produced by the body thatregulates blood pressure via vasoconstriction and sodium reabsorption.Hemodynamic effects of angiotensin II administration have been thesubject of numerous clinical studies, demonstrating significant effectson systemic and renal blood flow (Harrison-Bernard, L. M., The renalrenin-angiotensin system. Adv Physiol Educ, 2009. 33(4): p. 270-4.).Angiotensin II is a hormone produced by the renin angiotensinaldosterone system (RAAS) that modulates blood pressure via regulationof vascular smooth muscle tone and extracellular fluid homeostasis.Angiotensin II mediates its effects on the vasculature by inducingvasoconstriction and sodium retention, and so is the target of manytherapies for hypertension. In addition to its systemic effects,angiotensin II has a pronounced effect on the efferent arterioles of thekidney, maintaining glomerular filtration when blood flow is reduced.Angiotensin II also regulates sodium reabsorption in the kidney bystimulating Na+/H+ exchangers in the proximal tubule and inducing therelease of aldosterone and vasopressin (Harrison-Bernard, L. M., Therenal renin-angiotensin system. Adv Physiol Educ, 2009. 33(4): p.270-4.).

However, a paradoxical effect of angiotensin II occurs in patients withcirrhosis and ascites. Despite increasing sodium reabsorption in normalsubjects, angiotensin II induces marked natriuresis and urine output inpatients with cirrhosis and ascites, while inhibition of angiotensin inthese patients produces the opposite effect (i.e., reduced urine sodiumand output) (Ames, R. P., et al., Prolonged Infusions of Angiotensin Iiand Norepinephrine and Blood Pressure, Electrolyte Balance, andAldosterone and Cortisol Secretion in Normal Man and in Cirrhosis withAscites. J Clin Invest, 1965. 44: p. 1171-86; Lianos, E. A., et al.,Angiotensin-induced sodium excretion patterns in cirrhosis: role ofrenal prostaglandins. Kidney Int, 1982. 21(1): p. 70-7; Laragh, J. H.,et al., Angiotensin II, Norepinephrine, and Renal Transport ofElectrolytes and Water in Normal Man and in Cirrhosis with Ascites. JClin Invest, 1963. 42(7): p. 1179-92; McCloy, R. M., et al.,Angiotensin-induced natriuresis in cirrhosis in the absence ofendogenous aldosterone secretion. Ann Intern Med, 1966. 64(6): p.1271-6; Daskalopoulos, G., et al., Effects of captopril on renalfunction in patients with cirrhosis and ascites. J Hepatol, 1987. 4(3):p. 330-6.). The increase in urine output and sodium excretion due toangiotensin II is much more pronounced than those produced bynorepinephrine (Laragh, J. H. et al.). A second study (Ames, R. P., etal.) produced similar results, with angiotensin II causing a greaterincrease in sodium excretion compared to norepinephrine. Furthermore, inaccordance with these data, use of an angiotensin converting enzymeinhibitor (e.g., captopril) that inhibits production of angiotensin IIsignificantly reduced both sodium excretion and urinary output(Daskalopoulos, G., et al.).

The mechanism by which the differential activity of angiotensin IIaffects patients with cirrhosis and ascites is unknown, although variousmechanisms have been proposed. Lianos et al. have proposed that patientswith cirrhosis who respond to angiotensin II with natriuresis haveincreased intrarenal prostaglandin production. In this model, treatmentwith angiotensin II causes an increase in intrarenal prostaglandinrelease and improvement in glomerular filtration. Sansoé et al. haveproposed that these patients have inadequate production of angiotensinII despite circulating levels that are much higher than in normalindividuals (Sansoe, G., et al., Inappropriately low angiotensin IIgeneration: a factor determining reduced kidney function and survival inpatients with decompensated cirrhosis. J Hepatol, 2004. 40(3): p.417-23.). Coupled with findings from Newby et al. demonstrating thatcirrhotic patients have reduced responsiveness to angiotensin II (Newby,D. E., et al., Peripheral vascular tone in patients with cirrhosis: roleof the renin-angiotensin and sympathetic nervous systems. CardiovascRes, 1998. 38(1): p. 221-8.), it is possible that these patients have arelative deficiency of angiotensin II and reduced glomerular filtrationis the result of generalized vasodilation caused by this deficiency. Theincreased vasodilation has been attributed to increased nitric oxide(NO) synthesis (Helmy, A., et al., Nitric oxide mediates the reducedvasoconstrictor response to angiotensin II in patients with preasciticcirrhosis. J Hepatol, 2003. 38(1): p. 44-50.). While the exact mechanismof angiotensin II-induced sodium excretion has not been identified,plausible hypotheses exist.

Even though it was shown that angiotensin II induces marked natriuresisand urine output in the patients with cirrhosis and ascites, none of thepatients included in these studies exhibited renal failure. As currentvasoconstrictor therapy for HRS is limited in its ability to correctsodium dysregulation, angiotensin II may provide a significanttherapeutic advantage, since its use in patients with cirrhosis andascites has been well-tolerated.

In part, this disclosure demonstrates that a composition includingangiotensin II may be used to treat hepatorenal syndrome (HRS). Thetreatment is not limited to HRS and may include any renal failureassociated with cirrhosis or fulminant liver failure. It will beunderstood by those of skill in the art that this method may includetreatment of other diseases where a patient may benefit from theparadoxical effect of angiotensin II as described above, i.e., markednatriuresis and/or urine output. In some embodiments, HRS may be of typeI or type II. Renal failure itself may be associated with diseases suchas any type of cirrhosis (regardless of the cause), severe alcoholicand/or non-alcoholic hepatitis, fulminant hepatic failure, any infectionand/or injury causing deterioration in liver function, bleeding in thegastrointestinal tract, portal hypertension or elevated pressures inportal veins, nephrotic syndrome, ascites, infection of ascites fluid,complications of liver disease including removal of large volumes ofascitic fluid, overuse of diuretic medications, etc. Other causes ofascites that may result in renal failure include heart failure, hepaticvenous occlusion such as Budd-Chiari syndrome or veno-occlusive disease,constrictive pericarditis, Kwashiorkor (childhood protein-energymalnutrition), cancer (primary peritoneal carcinomatosis andmetastasis), infection such as tuberculosis or spontaneous bacterialperitonitis (SBP), pancreatitis, serositis, hereditary angioedema, Meigssyndrome, vasculitis, hypothyroidism, renal dialysis, peritoneummesothelioma. Causes of cirrhosis that may result in renal failure mayinclude alcoholic liver disease, non-alcoholic steatohepatitis,hepatitis C, hepatitis B, primary biliary cirrhosis, primary sclerosingcholangitis, autoimmune hepatitis, hereditary hemochromatosis, Wilson'sdisease, alpha 1-antitrypsin deficiency, cardiac cirrhosis,galactosemia, glycogen storage disease type IV, cystic fibrosis,hepatotoxic drugs or toxins, lysosomal acid lipase deficiency, etc.

Diagnostic Criteria

Several diagnostic criteria, individually or in combination, may be usedto determine if a patient is suffering from HRS or if the compositionincluding angiotensin II may be therapeutic to a particular patient. Thediagnostic criterion for HRS is serum creatinine level of greater than1.5 mg/dl. Patients with renal failure and cirrhosis that meet one ormore of the following criteria may also be candidates for angiotensintherapy. For example, patients having chronic or acute liver diseasewith advanced hepatic failure and/or portal hypertension; cirrhosis withascites; serum creatinine level of greater than 1.5 mg/dl and/or 24-hourcreatinine clearance of less than 40 ml/minute; no improvement of serumcreatinine (decrease to a level of less than or equal to 1.5 mg/dl)after at least two days of diuretic withdrawal and volume expansion withalbumin where the recommended dose of albumin may be 1 g/kg of bodyweight per day up to a maximum of 100 g/day; no sustained improvement inrenal function defined as a decrease in serum creatinine to less than1.5 mg/dL or increase in creatinine clearance to 40 mL/min or morefollowing diuretic withdrawal and expansion of plasma volume with 1.5 Lof isotonic saline; absence of shock, ongoing bacterial infection, andcurrent or recent treatment with nephrotoxic drugs; absence ofgastrointestinal fluid losses (repeated vomiting or intense diarrhea) orrenal fluid losses; proteinuria of less than 500 mg/dL and noultrasonographic evidence of obstructive uropathy or parenchymal renaldisease; absence of parenchymal kidney disease as indicated byproteinuria greater than 500 mg/day, microhematuria (greater than 50 redblood cells per high power field), and/or abnormal renalultrasonography; urine volume of less than 500 ml/day; urine sodium ofless than 10 mEq/L; urine osmolarity may be greater than plasmaosmolarity; urine red blood cells may be less than 50 per high powerfield, etc. may benefit from the angiotensin therapy.

Angiotensin II Therapeutics

The angiotensin II therapeutic that may be used for in the compositionsand methods of this disclosure may be Asp-Arg-Val-Tyr-Ile-His-Pro-Phe[SEQ ID NO: 1] also called 5-isoleucine angiotensin II. SEQ ID NO: 1 isan octa-peptide naturally present in humans and other species, such asequines, hogs, etc. The 5^(th) isoleucine may be substituted by valineto result in 5-valine angiotensin II, Asp-Arg-Val-Tyr-Val-His-Pro-Phe[SEQ ID NO: 2]. Other angiotensin II analogues such as[Asn¹-Phe⁴]-angiotensin II [SEQ ID NO: 3], hexapeptideVal-Tyr-Ile-His-Pro-Phe [SEQ ID NO: 4], nonapeptideAsn-Arg-Val-Tyr-Tyr-Val-His-Pro-Phe [SEQ ID NO: 5],[Asn¹-Ileu⁵-Ileu⁸]-angiotensin II [SEQ ID NO: 6],[Asn¹-Ileu⁵-Ala⁸]-angiotensin II [SEQ ID NO: 7], and[Asn¹-diiodoTyr⁴-Ileu⁵]-angiotensin II [SEQ ID NO: 8] may also be used.The term “angiotensin II”, without further specificity, is intended torefer to any of these various forms, as well as combinations thereof.

The sequence of angiotensin II used in the compositions and methodsdisclosed herein may be homologous to the sequences of angiotensin IIdescribed above. In certain embodiments, the invention includes isolatedor recombinant amino acid sequences that are at least 80%, 85%, 90%,95%, 97%, 98%, 99% or 100% identical to SEQ ID NO: 1, 2, 3, 4, 5, 6, 7,and/or 8. Any such variant sequences may be used in place of anangiotensin II as described in the preceding paragraph.

In some embodiments, the angiotensin II included in the composition usedfor the treatment may be selected from 5-valine angiotensin II acetate,5-valine angiotensin II amide, 5-L-isoleucine angiotensin II acetate,and 5-L-isoleucine angiotensin II amide, or a pharmaceuticallyacceptable salt thereof, preferably manufactured under current goodmanufacturing conditions (cGMP). In some embodiments, the compositionmay include different forms of angiotensin II in different percentages,e.g., a mixture of hexapeptide and nonapeptide angiotensin.

Similarly, an angiotensin II therapeutic may be used as any suitablesalt, deprotected form, acetylated form, deacetylated form, and/orprodrug form of the above-mentioned peptides, including pegylated formsof the peptides or conjugates as disclosed in US Patent Publication2011/0081371. The term “prodrug” refers to any precursor compound whichis able to generate or to release the above-mentioned peptide underphysiological conditions. Such prodrugs may be larger peptides which areselectively cleaved in order to form the peptide of the invention. Forexample, in some embodiments, the prodrug may be angiotensin I or itshomologues that may result in angiotensin II by the action of certainendogenous or exogenous enzymes. Further prodrugs include peptides withprotected amino acids, e.g., having protecting groups at one or morecarboxylic acid and/or amino groups. Suitable protecting groups foramino groups are the benzyloxycarbonyl, t-butyloxycarbonyl (BOC),formyl, and acetyl or acyl group. Suitable protecting groups for thecarboxylic acid group are esters such as benzyl esters or t-butylesters. The present invention also contemplates the use of angiotensinII and/or precursor peptides having amino acid substitutions, deletions,additions, the substitutions and additions including the standard D andL amino acids and modified amino acids, such as, for example, amidatedand acetylated amino acids, wherein the therapeutic activity of the basepeptide sequence is maintained at a pharmacologically useful level.

Doses of the Therapeutically Effective Substance

The term “pharmaceutically effective amount” or “therapeuticallyeffective amount” refers to an amount of the composition or therapeuticagent, such as angiotensin II, effective to treat renal failure in apatient, e.g., improving renal function, and/or effecting a beneficialand/or desirable alteration in the general health of a patient sufferingfrom a disease (e.g., renal failure). The skilled worker will recognizethat as used herein, the term “treating” or “treatment” includesreversing, reducing, or arresting the symptoms, clinical signs, andunderlying pathology of a condition in a manner to improve or stabilizea subject's condition. As used herein, and as well understood in theart, “treatment” is an approach for obtaining beneficial or desiredresults, including clinical results. Beneficial or desired clinicalresults can include, but are not limited to, alleviation or ameliorationof one or more symptoms or conditions, diminishment of extent of diseaseor its symptoms, stabilized (i.e., not worsening) state of disease orits symptoms, preventing spread of disease or its symptoms, delay orslowing of disease or its symptoms' progression, amelioration orpalliation of the disease state or its symptoms, and remission (whetherpartial or total), whether detectable or undetectable. “Treatment” canalso mean prolonging survival as compared to expected survival if notreceiving treatment. A “pharmaceutically effective amount” or“therapeutically effective amount” also refers to the amount required toimprove the clinical symptoms of a patient. The therapeutic methods ormethods of treating renal failure described herein are not to beinterpreted or otherwise limited to “curing” renal failure or thedisease causing the renal failure. When applied to an individual activeingredient, administered alone, the term refers to that ingredientalone. When applied to a combination, the term refers to combinedamounts of the active ingredients that result in the therapeutic effect,whether administered in combination, serially or simultaneously. Unlessotherwise specified, it is to be understood that each embodiment of theinvention may be used alone or in combination with any one or more otherembodiments of the invention.

In some embodiments, the total amount of a therapeutically effectivesubstance (e.g., angiotensin II) in a composition to be injected in apatient is one that is suitable for that patient. One of skill in theart would appreciate that different individuals may require differenttotal amounts of the angiotensin therapeutic. In some embodiments, theamount of the angiotensin therapeutic is a pharmaceutically effectiveamount. The skilled worker would be able to determine the amount of theangiotensin therapeutic in a composition needed to treat a patient basedon factors such as, for example, the age, weight, and physical conditionof the patient. The concentration of the angiotensin therapeutic (e.g.,angiotensin II) depends in part on its solubility in the intravenousadministration solution and the volume of fluid that can beadministered. For example, the rate of administration of the angiotensintherapeutic (e.g. angiotensin II) may be from about 0.032 ng/kg/min toabout 100 ug/kg/min in the injectable composition. In some embodiments,the rate of administration of the angiotensin therapeutic may be fromabout 0.4 to about 45 ug/min, from about 0.12 to about 19 ug/min, fromabout 3.8 to about 33.8 ug/min, from about 0.16 to about 2.6 ug/min,etc. In particular embodiments, the rate of administration of theangiotensin therapeutic may be about 0.032 ng/kg/min, about 0.1ng/kg/min, about 0.32 ng/kg/min, about 1 ng/kg/min, about 1.6 ng/kg/min,about 2 ng/kg/min, about 3 ng/kg/min, about 4 ng/kg/min, about 5ng/kg/min, about 6 ng/kg/min, about 7 ng/kg/min, about 8 ng/kg/min,about 9 ng/kg/min, about 10 ng/kg/min, about 15 ng/kg/min, about 20ng/kg/min, about 25 ng/kg/min, about 30 ng/kg/min, about 40 ng/kg/min,about 50 ng/kg/min, about 60 ng/kg/min, about 70 ng/kg/min, about 80ng/kg/min, about 90 ng/kg/min, about 100 ng/kg/min, about 200 ng/kg/min,about 300 ng/kg/min, about 400 ng/kg/min, about 500 ng/kg/min, about 600ng/kg/min, about 700 ng/kg/min, about 800 ng/kg/min, about 900ng/kg/min, about 1 ug/kg/min, about 1.1 ug/kg/min, about 1.2 ug/kg/min,about 1.3 ug/kg/min, about 1.4 ug/kg/min, about 1.5 ug/kg/min, about 1.5ug/kg/min, about 1.6 ug/kg/min, about 1.7 ug/kg/min, about 1.8ug/kg/min, about 1.9 ug/kg/min, about 2 ug/kg/min, about 2.1 ug/kg/min,about 2.2 ug/kg/min, about 2.3 ug/kg/min, about 2.4 ug/kg/min, about 2.5ug/kg/min, about 2.6 ug/kg/min, about 2.7 ug/kg/min, about 2.8ug/kg/min, about 2.9 ug/kg/min, about 3.0 ug/kg/min, about 3.1ug/kg/min, about 3.2 ug/kg/min, about 3.3 ug/kg/min, about 3.4ug/kg/min, about 3.5 ug/kg/min, about 3.6 ug/kg/min, about 3.7ug/kg/min, about 3.8 ug/kg/min, about 3.9 ug/kg/min, about 4.0ug/kg/min, about 4.1 ug/kg/min, about 4.2 ug/kg/min, about 4.3ug/kg/min, about 4.4 ug/kg/min, about 4.5 ug/kg/min, about 4.6ug/kg/min, about 4.7 ug/kg/min, about 4.8 ug/kg/min, about 4.9ug/kg/min, about 5.0 ug/kg/min, about 6 ug/kg/min, about 7 ug/kg/min,about 8 ug/kg/min, about 9 ug/kg/min, about 10 ug/kg/min, about 11ug/kg/min, about 12 ug/kg/min, about 13 ug/kg/min, about 14 ug/kg/min,about 15 ug/kg/min, about 16 ug/kg/min, about 17 ug/kg/min, about 18ug/kg/min, about 19 ug/kg/min, about 20 ug/kg/min, about 25 ug/kg/min,about 30 ug/kg/min, about 31 ug/kg/min, about 32 ug/kg/min, about 33ug/kg/min, about 33.8 ug/kg/min, about 34 ug/kg/min, about 35 ug/kg/min,about 40 ug/kg/min, about 45 ug/kg/min, about 50 ug/kg/min, about 55ug/kg/min, about 60 ug/kg/min, about 65 ug/kg/min, about 70 ug/kg/min,about 75 ug/kg/min, about 80 ug/kg/min, about 85 ug/kg/min, about 90ug/kg/min, about 95 ug/kg/min, about 100 ug/kg/min, etc.

The concentration of the angiotensin therapeutic (e.g., angiotensin II)in the composition administered can be at least 16 ug/ml. In someembodiments, the concentration of the angiotensin therapeutic may beabout 1.0 ug/ml, about 2.0 ug/ml, about 3.0 ug/ml, about 4.0 ug/ml,about 5.0 ug/ml, about 6.0 ug/ml, about 7.0 ug/ml, about 8.0 ug/ml,about 9.0 ug/ml, about 10.0 ug/ml, about 11.0 ug/ml, about 12.0 ug/ml,about 13.0 ug/ml, about 14.0 ug/ml, about 15.0 ug/ml, etc. In general,angiotensin II increases blood pressure, and patients with cirrhosis(who are hypotensive) may require larger doses to exhibit pressorresponses similar to those observed in normal subjects. The compositionincluding the angiotensin therapeutic (e.g., angiotensin II) can beadministered at a rate sufficient to achieve an increase in bloodpressure of at least about 10-15 mmHg and optionally for at leastangiotensin therapeutic administered may be varied in response tochanges in other physiological parameters such as renal vascularresistance, renal blood flow, filtration fractions, mean arterialpressure, etc. For example, the rate of administration of theangiotensin therapeutic may start from about 0.5 ng/kg/min to about 10ng/kg/min and is increased based on the mean arterial pressure (MAP). Insome embodiments, the rate of administration may be increased such thatthe MAP does not exceed about 70 mmHg, about 80 mmHg, about 90 mmHg,about 100 mmHg, about 110 mmHg, etc. For example, a patient may becoupled to a monitor that provides continuous, periodic, or occasionalmeasurements of MAP during some or all of the course of treatment. Therate of administration may be modulated manually (e.g., by a physicianor nurse) or automatically (e.g., by a medical device capable ofmodulating delivery of the composition in response to MAP valuesreceived from the monitor) to maintain the patient's MAP within adesired range (e.g., 80-110 mmHg) or below a desired threshold, e.g., asset forth above.

The composition including the angiotensin therapeutic may beadministered over a period of time selected from at least 8 hours; atleast 24 hours; and from 8 hours to 24 hours. The composition includingthe angiotensin therapeutic may be administered continuously for atleast 2-6 days, such as 2-11 days, continuously for 2-6 days, for 8hours a day over a period of at least 2-6 days, such as 2-11 days. Aweaning period (from several hours to several days) may be beneficialafter prolonged infusion.

The composition including the angiotensin therapeutic may furtherinclude one or more additional pharmaceutical agent. For example,angiotensin II may be administered with albumin since expansion of thevolume of the plasma with albumin given intravenously has shown toimprove renal function in patients with hepatorenal syndrome. Thequantity of the additional pharmaceutical agent administered may varydepending on the cumulative therapeutic effect of the treatmentincluding the angiotensin therapeutic and the additional pharmaceuticalagent. For example, the quantity of albumin administered may be 1 gramof albumin per kilogram of body weight given intravenously on the firstday, followed by 20 to 40 grams daily. Yet other additionalpharmaceutical agents may be any one or more of midodrine, octreotide,somatostatin, vasopressin analogue omnipressin, terlipressin,pentoxifylline, acetylcysteine, norepinephrine, misoprostol, etc. Insome embodiments, other natriuretic peptides may also be used incombination with the angiotensin therapeutic to remedy the impairment ofsodium excretion associated with diseases discussed above. For example,natriuretic peptides may include any type of atrial natriuretic peptide(ANP), brain natriuretic peptide (BNP), C-type natriuretic peptide(CNP), and/or dendroaspis natriuretic peptide, etc. Several diureticcompounds may be used in combination with the angiotensin therapeutic toinduce urine output. For example any one or more of the xanthines suchas caffeine, theophylline, theobromine; thiazides such asbendroflumethiazide, hydrochlorothiazide; potassium-sparing diureticssuch as amiloride, spironolactone, triamterene, potassium canrenoate;osmotic diuretics such as glucose (especially in uncontrolled diabetes),mannitol; loop diuretics such as bumetanide, ethacrynic acid,furosemide, torsemide; carbonic anhydrase inhibitors such asacetazolamide, dorzolamide; Na—H exchanger antagonists such as dopamine;aquaretics such as goldenrod, juniper; arginine vasopressin receptor 2antagonists such as amphotericin B, lithium citrate; acidifying saltssuch as CaCl₂, NH₄Cl; ethanol, water, etc. may be used in combinationwith the angiotensin therapeutic to treat the patient. The list ofadditional pharmaceutical agents described above is merely illustrativeand may include any other pharmaceutical agents that may be useful forthe treatment of renal failure associated with any of the diseases andconditions discussed above.

Excipients

The pharmaceutical compositions of the present invention may alsocontain diluents, fillers, salts, buffers, stabilizers, solubilizers,and other materials well known in the art. The term “pharmaceuticallyacceptable carrier” refers to a non-toxic carrier that may beadministered to a patient, together with a therapeutically effectivesubstance (such as angiotensin II) of this invention, and which does notdestroy the pharmacological activity of the therapeutically effectivesubstance. The term “pharmaceutically acceptable” means a non-toxicmaterial that does not interfere with the effectiveness of thebiological activity of the active ingredient(s). The characteristics ofthe carrier will depend on the route of administration. The term“excipient” refers to an additive in a formulation or composition thatis not a pharmaceutically active ingredient.

One of skill in the art would appreciate that the choice of any oneexcipient may influence the choice of any other excipient. For example,the choice of a particular excipient may preclude the use of one or moreadditional excipients because the combination of excipients wouldproduce undesirable effects. One of skill in the art would be able toempirically determine which excipients, if any, to include in thecompositions of the invention. Excipients of the invention may include,but are not limited to, co-solvents, solubilizing agents, buffers, pHadjusting agents, bulking agents, surfactants, encapsulating agents,tonicity-adjusting agents, stabilizing agents, protectants, andviscosity modifiers. In some embodiments, it may be beneficial toinclude a pharmaceutically acceptable carrier in the compositions of theinvention.

Solubilizing Agents

In some embodiments, it may be beneficial to include a solubilizingagent in the compositions of the invention. Solubilizing agents may beuseful for increasing the solubility of any of the components of theformulation or composition, including a therapeutically effectivesubstance (e.g., angiotensin II) or an excipient. The solubilizingagents described herein are not intended to constitute an exhaustivelist, but are provided merely as exemplary solubilizing agents that maybe used in the compositions of the invention. In certain embodiments,solubilizing agents include, but are not limited to, ethyl alcohol,tert-butyl alcohol, polyethylene glycol, glycerol, methylparaben,propylparaben, polyethylene glycol, polyvinyl pyrrolidone, and anypharmaceutically acceptable salts and/or combinations thereof.

pH-Adjusting Agents

In some embodiments, it may be beneficial to adjust the pH of thecompositions by including a pH-adjusting agent in the compositions ofthe invention. Modifying the pH of a formulation or composition may havebeneficial effects on, for example, the stability or solubility of atherapeutically effective substance, or may be useful in making aformulation or composition suitable for parenteral administration.pH-adjusting agents are well known in the art. Accordingly, thepH-adjusting agents described herein are not intended to constitute anexhaustive list, but are provided merely as exemplary pH-adjustingagents that may be used in the compositions of the invention.pH-adjusting agents may include, for example, acids and bases. In someembodiments, a pH-adjusting agent includes, but is not limited to,acetic acid, hydrochloric acid, phosphoric acid, sodium hydroxide,sodium carbonate, and combinations thereof.

The pH of the compositions of the invention may be any pH that providesdesirable properties for the formulation or composition. Desirableproperties may include, for example, therapeutically effective substance(e.g., angiotensin II) stability, increased therapeutically effectivesubstance retention as compared to compositions at other pHs, andimproved filtration efficiency. In some embodiments, the pH of thecompositions of the invention may be from about 3.0 to about 9.0, e.g.,from about 5.0 to about 7.0. In particular embodiments, the pH of thecompositions of the invention may be 5.5±0.1, 5.6±0.1, 5.7±0.1, 5.8±0.1,5.9±0.1, 6.0±0.1, 6.1±0.1, 6.2±0.1, 6.3±0.1, 6.4±0.1, or 6.5±0.1.

Buffers

In some embodiments, it may be beneficial to buffer the pH by includingone or more buffers in the compositions. In certain embodiments, abuffer may have a pKa of, for example, about 5.5, about 6.0, or about6.5. One of skill in the art would appreciate that an appropriate buffermay be chosen for inclusion in compositions of the invention based onits pKa and other properties. Buffers are well known in the art.Accordingly, the buffers described herein are not intended to constitutean exhaustive list, but are provided merely as exemplary buffers thatmay be used in the compositions of the invention. In certainembodiments, a buffer may include one or more of the following: Tris,Tris HCl, potassium phosphate, sodium phosphate, sodium citrate, sodiumascorbate, combinations of sodium and potassium phosphate, Tris/TrisHCl, sodium bicarbonate, arginine phosphate, arginine hydrochloride,histidine hydrochloride, cacodylate, succinate,2-(N-morpholino)ethanesulfonic acid (MES), maleate, bis-tris, phosphate,carbonate, and any pharmaceutically acceptable salts and/or combinationsthereof.

Surfactants

In some embodiments, it may be beneficial to include a surfactant in thecompositions of the invention. Surfactants, in general, reduce thesurface tension of a liquid composition. This may provide beneficialproperties such as improved ease of filtration. Surfactants also may actas emulsifying agents and/or solubilizing agents. Surfactants are wellknown in the art. Accordingly, the surfactants described herein are notintended to constitute an exhaustive list, but are provided merely asexemplary surfactants that may be used in the compositions of theinvention. Surfactants that may be included include, but are not limitedto, sorbitan esters such as polysorbates (e.g., polysorbate 20 andpolysorbate 80), lipopolysaccharides, polyethylene glycols (e.g., PEG400 and PEG 3000), poloxamers (i.e., pluronics), ethylene oxides andpolyethylene oxides (e.g., Triton X-100), saponins, phospholipids (e.g.,lecithin), and combinations thereof.

Tonicity-Adjusting Agents

In some embodiments, it may be beneficial to include atonicity-adjusting agent in the compositions of the invention. Thetonicity of a liquid composition is an important consideration whenadministering the composition to a patient, for example, by parenteraladministration. Tonicity-adjusting agents, thus, may be used to helpmake a formulation or composition suitable for administration.Tonicity-adjusting agents are well known in the art. Accordingly, thetonicity-adjusting agents described herein are not intended toconstitute an exhaustive list, but are provided merely as exemplarytonicity-adjusting agents that may be used in the compositions of theinvention. Tonicity-adjusting agents may be ionic or non-ionic andinclude, but are not limited to, inorganic salts, amino acids,carbohydrates, sugars, sugar alcohols, and carbohydrates. Exemplaryinorganic salts may include sodium chloride, potassium chloride, sodiumsulfate, and potassium sulfate. An exemplary amino acid is glycine.Exemplary sugars may include sugar alcohols such as glycerol, propyleneglycol, glucose, sucrose, lactose, and mannitol.

Stabilizing Agents

In some embodiments, it may be beneficial to include a stabilizing agentin the compositions of the invention. Stabilizing agents help increasethe stability of a therapeutically effective substance in compositionsof the invention. This may occur by, for example, reducing degradationor preventing aggregation of a therapeutically effective substance.Without wishing to be bound by theory, mechanisms for enhancingstability may include sequestration of the therapeutically effectivesubstance from a solvent or inhibiting free radical oxidation of theanthracycline compound. Stabilizing agents are well known in the art.Accordingly, the stabilizing agents described herein are not intended toconstitute an exhaustive list, but are provided merely as exemplarystabilizing agents that may be used in the compositions of theinvention. Stabilizing agents may include, but are not limited to,emulsifiers and surfactants.

Routes of Delivery

The compositions of the invention can be administered in a variety ofconventional ways. In some embodiments, the compositions of theinvention are suitable for parenteral administration. These compositionsmay be administered, for example, intraperitoneally, intravenously,intrarenally, or intrathecally. In some embodiments, the compositions ofthe invention are injected intravenously. One of skill in the art wouldappreciate that a method of administering a therapeutically effectivesubstance formulation or composition of the invention would depend onfactors such as the age, weight, and physical condition of the patientbeing treated, and the disease or condition being treated. The skilledworker would, thus, be able to select a method of administration optimalfor a patient on a case-by-case basis.

Unless otherwise defined herein, scientific and technical terms used inthis application shall have the meanings that are commonly understood bythose of ordinary skill in the art. Generally, nomenclature andtechniques relating to chemistry, molecular biology, cell and cancerbiology, immunology, microbiology, pharmacology, and protein and nucleicacid chemistry, described herein, are those well known and commonly usedin the art.

Throughout this specification, the word “comprise” or variations such as“comprises” or “comprising” will be understood to imply the inclusion ofa stated integer (or components) or group of integers (or components),but not the exclusion of any other integer (or components) or group ofintegers (or components). The singular forms “a,” “an,” and “the”include the plurals unless the context clearly dictates otherwise. Theterm “including” is used to mean “including but not limited to.”“Including” and “including but not limited to” are used interchangeably.The terms “patient” and “individual” are used interchangeably and referto either a human or a non-human animal These terms include mammals suchas humans, primates, livestock animals (e.g., bovines, porcines),companion animals (e.g., canines, felines) and rodents (e.g., mice,rabbits and rats).

“About” and “approximately” shall generally mean an acceptable degree oferror for the quantity measured given the nature or precision of themeasurements. Typically, exemplary degrees of error are within 20%,preferably within 10%, and more preferably within 5% of a given value orrange of values. Alternatively, and particularly in biological systems,the terms “about” and “approximately” may mean values that are within anorder of magnitude, preferably within 5-fold and more preferably within2-fold of a given value. Numerical quantities given herein areapproximate unless stated otherwise, meaning that the term “about” or“approximately” can be inferred when not expressly stated.

Incorporation by Reference

All publications and patents mentioned herein are hereby incorporated byreference in their entirety as if each individual publication or patentwas specifically and individually indicated to be incorporated byreference. In case of conflict, the present specification, including itsspecific definitions, will control. While specific embodiments of thesubject matter have been discussed, the above specification isillustrative and not restrictive. Many variations will become apparentto those skilled in the art upon review of this specification and theclaims below. The full scope of the invention should be determined byreference to the claims, along with their full scope of equivalents, andthe specification, along with such variations.

We claim:
 1. A method of treating renal failure associated withcirrhosis in a patient in need thereof, comprising administering to thepatient a composition comprising angiotensin II.
 2. The method of claim1, wherein, prior to administration, the patient has a serum creatininelevel greater than 1.5 mg/dl.
 3. The method of claim 1, wherein, priorto administration, the patient has a 24-hour serum creatinine clearanceof less than 40 ml/min.
 4. A method of treating renal failure associatedwith cirrhosis in a patient in need thereof, comprising: measuring serumcreatinine level and/or 24-hour serum creatinine clearance of a patient;and if a) the measured serum creatinine level is greater than 1.5 mg/dland/or b) the measured 24-hour serum creatinine clearance is less than40 ml/min, administering to the patient a composition comprisingangiotensin II.
 5. The method of claim 1, wherein the renal failure ishepatorenal syndrome.
 6. The method of claim 1, wherein the patient is ahuman.
 7. The method of claim 6, comprising administering theangiotensin II at a rate equal to or greater than 0.032 ng/kg/min, 0.32ng/kg/min, 1.6 ng/kg/min, or 1 ng/kg/min; or at a rate in the range of0.5 ng/min to 100 ug/min, 0.4 to 45 ug/min or 0.12 to 19 ug/min.
 8. Themethod of claim 6, wherein the composition has a concentration of theangiotensin II of at least 16 ug/ml.
 9. The method of claim 6,comprising administering the composition at a rate sufficient to achievean increase in blood pressure of at least about 10-15 mmHg andoptionally continuing to administer for at least about 30 minutesthereafter.
 10. The method of claim 6, comprising administering thecomposition at a variable rate based on mean arterial pressure in thepatient, wherein the mean arterial pressure does not exceed 80 mmHg, 90mmHg, 100 mmHg, 110 mmHg or 120 mmHg.
 11. The method of claim 1,comprising administering the composition over a period of time selectedfrom at least 8 hours; at least 24 hours; and from 8 hours to 24 hours.12. The method of claim 1, comprising administering the compositioncontinuously for at least 2-6 days, such as 2-11 days.
 13. The method ofclaim 12, comprising administering the composition continuously for 2-6days.
 14. The method of claim 1, wherein the composition is administeredfor 8 hours a day over a period of at least 2-6 days, such as 2-11 days.15. A method of assessing the response of a patient with renal failureassociated with cirrhosis to angiotensin therapy, comprisingadministering to the patient an initial dose of a composition comprisingangiotensin II and testing the patient for a change in a therapeuticparameter.
 16. The method of claim 15, wherein the therapeutic parameteris serum creatinine level, estimated glomerular filtration rate, serumsodium level, serum potassium level, urine sodium concentration, orblood pressure.
 17. The method of claim 16, wherein a decrease in thepatient's serum creatinine level, urine sodium concentration, or serumpotassium level or an increase in the patient's blood pressure, serumsodium level, or estimated glomerular filtration rate is indicative of apositive response to the angiotensin therapy.
 18. The method of claim17, further comprising, if the patient has a positive response,administering an additional dose of angiotensin II to the patient. 19.The method of claim 15, further comprising, prior to administering thecomposition to the patient, measuring serum creatinine level and/or24-hour serum creatinine clearance of the patient; and if a) themeasured serum creatinine level is greater than 1.5 mg/dl and/or b) themeasured 24-hour serum creatinine clearance is less than 40 ml/min,administering to the patient the composition.
 20. The method of claim15, wherein testing is performed at least half an hour afteradministering, preferably at least one hour.
 21. The method of claim 15,wherein testing is performed less than eight hours after administering,preferably less than 6 hours.
 22. The method of claim 15, wherein theinitial dose is less than 1 ng/kg/min or about 1 ng/kg/min.
 23. Themethod of claim 1, wherein the angiotensin II is 5-valine angiotensin IIacetate, 5-valine angiotensin II amide, 5-L-isoleucine angiotensin IIacetate, and 5-L-isoleucine angiotensin II amide, or a pharmaceuticallyacceptable salt thereof.
 24. The method of claim 1, wherein thecomposition is suitable for parenteral administration.
 25. The method ofclaim 24, wherein the parenteral administration is injection orintravenous infusion.
 26. The method of claim 1, wherein the compositionfurther comprises an additional pharmaceutical agent.
 27. The method ofclaim 26, wherein the additional pharmaceutical agent is useful for thetreatment of the renal failure associated with cirrhosis.
 28. The methodof claim 26, wherein the additional pharmaceutical agent isterlipressin, norepinephrine, or midodrine.